HEALTH TRAIN EXPRESS
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Monday, July 29, 2013

Some say that Concierge medicine and Direct Pay are two different forms of payment. Not so.

This should not be complicated.

Medical Access USA is an old and well established method for patients to access quality health care and were discussing how to build a system.

Accountability is a trust relationship and is a one-on-one transaction. Our goal at Medical Access is to restore the relationship between patient and provider to ensure that connection. Our mechanism is a fee-for-service model. Despite recent moves to discourage and eliminate this mechanism for many reasons unrelated to practicing quality health care, it should not disappear. It provides a simplicity without complex indecipherable regulations. It also reduces the overhead of billing (64% for an individual primary care physician )according to some sources)

How do we go about changing health reimbursement in a meaningful way for many patients. Notice I did not say all patients. That would be as foolhardy as what the Democrats and President Obama accomplished with the Affordable Care Act.

The prime directive for our plan is patient welfare and the ability to access primary care easily and affordably. It does not take a rocket scientist to analyze what needs to be done. The Affordable Care Act favors a medical home. This used to be called a family or general medical practice. The name changed but the core premise remains the same. Another term would be ‘holistic medical practice’. Patients do well and favor having a physician who can manage most of their issues. Many health related problems have an underlying psycho-social component and requires a transference between patient and physician. This is reinforced by visiting with the same physician.

The basic care unit is one doctor and one patient. Patient pays doctor for services, a one-on-one contract with no intermediary.

Wednesday, July 24, 2013

Many of these issues also apply to healthcare and medicine. Rushing to satisfy requirements for new technology and unproven organizational models often leads to loss of productivity, inappropriate expenditures, and disaster for organizations.

You might be thinking “why else would people work if not to enrich themselves?” This is certainly the view of human nature that dominates economics. In The Wealth of Nations, the father of modern economics, Adam Smith wrote:

It is in the inherent interest of every man to live as much at his ease as he can; and if his emoluments are to be precisely the same whether he does or does not perform some very laborious duty, to perform it in as careless and slovenly a manner that authority will permit.

Thus, for Smith, if you wanted people to do an honest day’s work, you had to make it pay. The discipline of economics has been guided by this assumption ever since. And the management practices of organizations in all areas of life have borne the mark of this view. But even within this framework, people realized that there was more to work and life than instrumental incentives. For example, Goldman Sachs, the investment bank that was one of the villains of the financial collapse, was guided in its earlier days by “service to client” as its touchstone. It was only after Goldman Sachs became a public company that it evolved into a money-making machine.

Does this sound like health care ? The cost of doing business, health or otherwise increases with bureaucracy, and like “teaching to the test” creates more efficiency to produce more income and incentivizes the wrong goals.

Yes, “what’s in it for me” was a part of human nature, but so were virtues like honesty, integrity, loyalty, pride, responsibility, duty, commitment, and courage. Indeed, even Adam Smith made it clear in The Theory of Moral Sentiments, that he didn’t think the economic side of human beings told the whole story. But nowadays, we tend to see human motivation as uni-dimensional, at least when it comes to designing our institutions. What is odd is that although we seem readily to accept this view when it comes to other people, we reject it completely when we’re thinking about ourselves.

There is no doubt that some incentives are smarter than others. But incentives are, by their nature, limited in what they can accomplish, and thus not the right tool for every objective. Worse yet, incentives can have perverse effects, undermining the moral commitments people might otherwise have to pursue the telos of their chosen profession.

Psychologists have known this for years, but policy makers have not been paying attention. In this connection, it is interesting to note that the “normalization” of incentives is a relatively recent historical phenomenon. In earlier eras, they were regarded with distaste as nothing more than bribes. They were not the same as rewards and punishments, because rewards and punishments imply merit or desert. They were just levers that one could use to make people do what you wanted them to do. Owing, I think, to the pervasive influence of economics, and to developments in the discipline of management science, incentives slowly evolved into morally neutral management tools. One consequence is that questions about what the right thing to do is were less and less commonly asked.

If people aren’t asking themselves what’s the right thing to do, they are not likely to do the right thing. And as a result, the public will stop trusting them, as indeed, it should.

Many of these issues also apply to healthcare and medicine. Rushing to satisfy requirements for new technology and unproven organizational models often leads to loss of productivity, inappropriate expenditures, and disaster for organizations.

You might be thinking “why else would people work if not to enrich themselves?” This is certainly the view of human nature that dominates economics. In The Wealth of Nations, the father of modern economics, Adam Smith wrote:

It is in the inherent interest of every man to live as much at his ease as he can; and if his emoluments are to be precisely the same whether he does or does not perform some very laborious duty, to perform it in as careless and slovenly a manner that authority will permit.

Thus, for Smith, if you wanted people to do an honest day’s work, you had to make it pay. The discipline of economics has been guided by this assumption ever since. And the management practices of organizations in all areas of life have borne the mark of this view. But even within this framework, people realized that there was more to work and life than instrumental incentives. For example, Goldman Sachs, the investment bank that was one of the villains of the financial collapse, was guided in its earlier days by “service to client” as its touchstone. It was only after Goldman Sachs became a public company that it evolved into a money-making machine.

Does this sound like health care ? The cost of doing business, health or otherwise increases with bureaucracy, and like “teaching to the test” creates more efficiency to produce more income and incentivizes the wrong goals.

Yes, “what’s in it for me” was a part of human nature, but so were virtues like honesty, integrity, loyalty, pride, responsibility, duty, commitment, and courage. Indeed, even Adam Smith made it clear in The Theory of Moral Sentiments, that he didn’t think the economic side of human beings told the whole story. But nowadays, we tend to see human motivation as uni-dimensional, at least when it comes to designing our institutions. What is odd is that although we seem readily to accept this view when it comes to other people, we reject it completely when we’re thinking about ourselves.

There is no doubt that some incentives are smarter than others. But incentives are, by their nature, limited in what they can accomplish, and thus not the right tool for every objective. Worse yet, incentives can have perverse effects, undermining the moral commitments people might otherwise have to pursue the telos of their chosen profession.

Psychologists have known this for years, but policy makers have not been paying attention. In this connection, it is interesting to note that the “normalization” of incentives is a relatively recent historical phenomenon. In earlier eras, they were regarded with distaste as nothing more than bribes. They were not the same as rewards and punishments, because rewards and punishments imply merit or desert. They were just levers that one could use to make people do what you wanted them to do. Owing, I think, to the pervasive influence of economics, and to developments in the discipline of management science, incentives slowly evolved into morally neutral management tools. One consequence is that questions about what the right thing to do is were less and less commonly asked.

If people aren’t asking themselves what’s the right thing to do, they are not likely to do the right thing. And as a result, the public will stop trusting them, as indeed, it should.

Disrespect goes far beyond the nurse-doctor patient interface with patients. We are leaving out the most disrespectful aspects of our present system.

These are the under-insured and uninsured patients.

The middle level managers with cookbook guidelines to denials and authorizations for diagnostic procedures, treatments and access to expensive pharmaceuticals.

The insurance company unreasonably denying treatments, the endless waiting in a phone queue only to be answered by a robot.

The informed consent written by attorneys that are unintelligible. The Medicaid system which treats recipients with disdain and rules that are byzantine, with addendums and empty promises of a safety net, obsolete and irrelevant poverty figures as well as month to month eligibility which obviates any form of managed care or case management.

The incompetent legislatures who rule from above with no concept of safe and/or effective healthcare.

The autocratic and dictatorial methods of the Department of Health and Human Services.

Friday, July 19, 2013

California is large enough to be called a ‘nation-state’ with 35 million citizens, it is larger than many sovereign states in the world. The diversity of it’s demographic is challenging not only for health systems and providers, and with social engineers as well.

The development of health information exchanges in California is a microcosm for what must take place nationally in regard to health reform and ObamaCare.

Early study and planning for HIX began in 2004 with a major impetus by the newly formed Office of the National Coordinator for Health Information Technology (ONCHIT). Rather than forming one monolithic organization a model for regional information exchanges evolved over time.

Simultaneous interoperability standards were developed to ensure a common system of harmony between disparate EMR system, laboratory systems, pharmacy systems and more.

Federal incentives in the form of the HITECH Act has fueled significant growth in HIT since 2009.

The most recent meeting of the CAeHQ nicely summarizes the progress of health information exchanges, and it’s relationship to the national plan. It is anticipated that as the system matures individual HIOs may vanish to be replaced by the national HIE.

The development of each individual health information exchange has been sporadic and dependent upon local interests and the development of sustainable business models. Other items include trust agreements among the users of the exchanges.

Whilst some HIXs are working well, each one delivers different data fields and the comprehensiveness of it’s data. Some are simple messaging functionality, some allow transmission of continuity of care records, while others are more complete.

As yet there is little if any transparency from an electronic medical record. Rather than true integration of the data into a trusted partner’s EMR a separate portal must be engaged to retrieve patient data.

The ONCHIT Direct program remains a national infrastructure, while each region has it’s own network. There is no uniformity of size. The current size appears to be guided by the hospital systems and the individual state. Few cross state jurisdictions except for a few.

The CAeHQC recent stakeholder meeting took place on July 18,2013 via a webinar.

California is large enough to be called a ‘nation-state’ with 35 million citizens, it is larger than many sovereign states in the world. The diversity of it’s demographic is challenging not only for health systems and providers, and with social engineers as well.

The development of health information exchanges in California is a microcosm for what must take place nationally in regard to health reform and ObamaCare.

Early study and planning for HIX began in 2004 with a major impetus by the newly formed Office of the National Coordinator for Health Information Technology (ONCHIT). Rather than forming one monolithic organization a model for regional information exchanges evolved over time.

Simultaneous interoperability standards were developed to ensure a common system of harmony between disparate EMR system, laboratory systems, pharmacy systems and more.

Federal incentives in the form of the HITECH Act has fueled significant growth in HIT since 2009.

The most recent meeting of the CAeHQ nicely summarizes the progress of health information exchanges, and it’s relationship to the national plan. It is anticipated that as the system matures individual HIOs may vanish to be replaced by the national HIE.

The development of each individual health information exchange has been sporadic and dependent upon local interests and the development of sustainable business models. Other items include trust agreements among the users of the exchanges.

Whilst some HIXs are working well, each one delivers different data fields and the comprehensiveness of it’s data. Some are simple messaging functionality, some allow transmission of continuity of care records, while others are more complete.

As yet there is little if any transparency from an electronic medical record. Rather than true integration of the data into a trusted partner’s EMR a separate portal must be engaged to retrieve patient data.

The ONCHIT Direct program remains a national infrastructure, while each region has it’s own network. There is no uniformity of size. The current size appears to be guided by the hospital systems and the individual state. Few cross state jurisdictions except for a few.

The CAeHQC recent stakeholder meeting took place on July 18,2013 via a webinar.

Tuesday, July 16, 2013

Never events refer to hospital mishaps in procedures and patient identification which often lead to severe complications, loss of a limb and/or death. Perhaps the term should also be applied to privacy rules:

It is forbidden:

The Privacy Rule allows a covered entity to de-identify data by removing all 18 elements that could be used to identify the individual or the individual's relatives, employers, or household members; these elements are enumerated in the Privacy Rule. The covered entity also must have no actual knowledge that the remaining information could be used alone or in combination with other information to identify the individual who is the subject of the information. Under this method, the identifiers that must be removed are the following:

Names.

All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes, except for the initial three digits of a ZIP Code if, according to the current publicly available data from the Bureau of the Census:

The geographic unit formed by combining all ZIP Codes with the same three initial digits contains more than 20,000 people.

The initial three digits of a ZIP Code for all such geographic units containing 20,000 or fewer people are changed to 000.

All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older.

Any other unique identifying number, characteristic, or code, unless otherwise permitted by the Privacy Rule for re-identification.

These categories are subject to fines, and penalties and in some cases prison sentences for violations (if repeated, and uncorrected)

It extends to insurance agents, insurers, Medicare, providers, hospitals and other health care entities, including health information exchanges,health benefit exchanges, government web sites (CMS, Medicaid), Social Security Records,social media, blogs, including archived storage media, cloud storage, and the Internal Revenue Service should they act as an enforcement agency for the terms of the individual mandate (subject to final rulings of the affordable care act.

In essence HIPAA extends privacy rules to anyone in contact with digitized or written information about patients, INCLUDING NAVIGATORS. Let us anticipate they will be trained in HIPAA regulations.

Covered entities may also use statistical methods to establish de-identification instead of removing all 18 identifiers. The covered entity may obtain certification by "a person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable" that there is a "very small" risk that the information could be used by the recipient to identify the individual who is the subject of the information, alone or in combination with other reasonably available information. The person certifying statistical de-identification must document the methods used as well as the result of the analysis that justifies the determination. A covered entity is required to keep such certification, in written or electronic format, for at least 6 years from the date of its creation or the date when it was last in effect, whichever is later.

Monday, July 15, 2013

1581: Francis Drake, having completed the first circumnavigation of the world a few months earlier, is knighted by Queen Elizabeth aboard his ship, the Golden Hind

Do we need navigators on the high turbulent seas of the Affordable Care Act ?

The Department of HHS as part of the Affordable Care Act mandated a Navigator program to help people enroll in insurance plans. Why they did this is no mystery.

They estimated that licensed insurance brokers would ‘gain the system’ to their advantage. I wonder what the evidence is for that?

There is much evidence which justifies these concerns found on the internet just by searching for “Medicare enrollment”. A search will take you to many sites for health insurance, besides Medicare….most seem to be profit driven Medicare advantage of private insurance companies of varying credibility. The actual CMS or Medicare.gov sites are buried several pages down in the search results.

Individuals who work in the Affordable Care Act's "navigator" program for the law's health insurance exchanges must be affiliated with certain community organizations, such as churches. The workers must undergo at least 30 hours of training to before they can be qualified as a "certified application counselor," the rule issued by CMS states

Under the ACA, exchanges that will be operated solely by or in partnership with the federal government are required to have at least two certified navigator entities, one of which must be a not-for-profit. HHS has allocated $54 million in funding grants to train and pay navigators in the 37 states with federally run exchanges.

Navigator workers must provide "fair, impartial and accurate information that assists consumers with submitting the eligibility application, clarifying distinctions among [qualified health plans] and helping qualified individuals make informed decisions during the health plan selection process." They also must provide additional assistance to:

Consumers with disabilities, limited proficiency in English; or

Consumers who are unfamiliar with health insurance.

Lawmakers in recent months have raised concerns about the workers' level of training and access to consumers' personal and potentially sensitive data. In particular, some GOP leaders have stepped up their scrutiny of the navigator program and a separate "in-person assisters" program in states that will operate their own exchanges. The ACA prohibits federal funding for the assisters program because it does not have to meet the same criteria as the navigators program..

More Details of Final Rule

Under the final rule, traditional insurance agents cannot be selected and trained as navigator workers, who must not be affiliated with the insurance industry ("Healthwatch," The Hill, 7/12). Navigator workers and in-person assisters can provide information only about specific topics.

Jones, Groups See Fraud Potential in Covered California Enrollment

California Insurance Commissioner Dave Jones (D) and consumer advocacy groups are concerned about the potential for fraud and identity theft when individuals enroll in the California Health Insurance Exchange .

Privacy, Fraud Concerns

Jones and consumer groups say that the exchange is not doing enough to ensure that people hired as enrollment counselors -- individuals who will provide consumers with in-person assistance in signing up for health plans -- are adequately screened and monitored.

The network of more than 21,000 enrollment counselors could have access to consumers' personal and financial information, such as ID cards and medical histories.

According to Jones, the exchange does not have a plan for investigating any complaints that could arise once the counselors begin their work.

Jones said that it will be possible for the counselors to "obtain information that will allow them to build the trust they have with the individual they're working with and potentially sell them all manner of bogus products, steal their identity, gain access to certain assets they might have ... The list is virtually endless."

He added, "We can have a real disaster on our hands." Unless the navigators are certified as HIPAA compliant entity

Sunday, July 14, 2013

"But I don't want to go among mad people," Alice remarked."Oh, you can't help that," said the Cat:We're all mad here. I'm mad. You're mad.""How do you know I'm mad?" said Alice."You must be," said the Cat,"Or you wouldn't have come here."

Would anyone believe that a well intentioned law (Affordable Care Act) would wreak havoc with an already dysfunctional health system? That is about to happen.

The discord is not just a partisan issue, Republican vs. Democrat. Neither side gives a damn about reality, or budgetary constraints.

Haste will make waste, and the implementation of the ACA must be put on hold, for several years.

Some could look upon the Affordable Care Act as a plan for improving health by ‘guaranteeing health insurance to all. This however does not take into account the myriad complexity and reality of health and disease.

In 2010 the Affordable Care Act was passed into law. The law was passed unanimously by the democratic majority in Congress without Republican support. Due to our congressional structure roughly 1/2 of the country was disenfranchised in regard to decisions on health finance reform..

This produced much discontent which has gradually increased and even effected the supporters of the bill.

Many of the specific mandates are schedule to become effective on January 1, 2014.

White House delays employer mandateBending to criticism that requirements were burdensome and complex, the Obama Administration announced late Tuesday it would delay until 2015 a key provision in the healthcare reform law -- the requirement that businesses with more than 50 employees must offer them insurance. This portion of the ACA would force employers to offer health coverage to all full time employees, and require businesses with more than 50 employees to meet certain other requirements of the ACA.

Secondary consequences of the ACA are considerable, increased unemployment, increased part time work force, decreased hiring and loss of entrepreneurial spirit. The ACA increases the risk and cost of expanding a business. All of these changes will be put on hold until January 2015.

Physicians remain concerned over the future of U.S. healthcare, a new survey reveals. Among the survey’s findings, most physicians think EHRs and the ACA will adversely affect the quality of patient care, and nearly two-thirds anticipate that quality of healthcare will worsen over the next five years.

This year's PSI tells a story of over-burdened physicians who are deeply concerned about where the healthcare industry is headed. The data suggests the leading distractions affecting physicians' ability to provide the optimum care for patients center on government intervention, increased utilization of and frustration with EHRs and administrative burdens. All told, these distractions have diminished physicians' optimism around their ability to deliver quality care and remain viable, profitable practices.

73 percent said EHRs are a distraction to doctor-patient interaction, up 12 percentage points from 2011.

The number who purchased an EHR jumped 10 percentage points between 2011 and 2012 (from 70 percent to 80 percent). – Yet, very favorable opinions did not move in line –18 percent fewer voiced a very favorable opinion of EHRs (from 39 percent in 2011 to 32 percent in 2012).

The majority (44 percent) says that the EHR was not designed with physicians in mind versus 32 percent in 2011

Doctors skeptical of regulation

Over half (in 2012 and 2011) say that government involvement in regulation will not yield lower costs and better outcomes, with slightly more pessimism on display this year.

A growing number concerned about the ACA’s impact on the quality of care: Nearly one-third (29 percent) say they still do not understand the details and implications, compared to 22 percent in 2011.

16 percent said they'd like to see the ACA remain 'as is' (versus 11 percent in 2011).

53 percent report the ACA will have a detrimental effect on their ability to provide high quality care, versus 50 percent in 2011 – 43 percent more believe the ACA will be very detrimental to the delivery of quality of care (from 14 percent in 2011 to 20 percent in 2012).

Three-quarters report that the meaningful use process is at least somewhat difficult and/or cumbersome.

The ACO model draws concerns: More indicated ACOs as having a negative impact on quality of care (39 percent in 2012 versus 26 percent in 2011) and profitability (63 percent in 2012 versus 48 percent in 2011

Saturday, July 6, 2013

I thought of several ways to title this post. 1. Changes in Battlefield Medicine 2.Educational opportunities on line at MYVEHU. 3.What non-VA physicians should know about VA and/or Military Medicine.

This post seemed timely as we have just celebrated our freedoms and liberties defended by our warriors some of whom become severely wounded and challenged from their wounds. It also may explain the increased number of multiple limb amputees and how their mortality has been drastically reduced, and how advanced technology is brought to the battlefield hospital for intervention during the window of opportunity within one hour of the injury. This is no accident and is due to carefully orchestrated teamwork of the involved professionals on the battlefield

There is a lesson to be learned for civilian medical care, both acute and chronic. ln our present system the majority of MDs practice in a relatively isolated clinic environment. Most of their professional organization takes place in the hospital as a member of the medical staff and their specialty department. There is little opportunity to engage other specialists not in their own field. The individual excellence of each physician is in a silo (much like health information)

Civilians medicine is in the process of transitioning from the old model into one of integrated systems, and accountable care organizations, capable of using military models of care.

With this introduction, let’s move on to some specifics about the VA system, and also the medical departments of the armed services.

The Veteran’s Administration Health System offers continuing medical education for physicians and care-givers online, similar to many offerings for CME from universities and accredited programs.

MYVEHU is a source for VA personnel that also features topics relevant to the reorganization of civilian systems

Disclaimer

The opinions in this blog or other forms of social media are solely that of Gary M. Levin M.D. Dr. Levin has no financial interests in any medical devices which are discussed or which appear in the blog. Commentary taken from other sources are either quoted or referenced with attribution. Dr Levin does not endorse, nor give financial support to any political organizations.